July 13 (Bloomberg) -- As research shows the risks of
delivering babies before they’re ready, insurers from Aetna Inc.
to Cigna Corp. are nudging hospitals and doctors to scale back
induced births and cesarean surgeries.

A decades-long move toward scheduled births has helped make
the C-section the most common surgery in the U.S., accounting
for a third of all deliveries, according to federal statistics.
More troubling, the procedures are coming earlier in pregnancy,
raising costs as well as the risk of complications. Insurers are
starting to push back.

“We’ve known the risks of these procedures for a long
time, yet the rates continue to rise,” said Maureen Corry,
executive director at Childbirth Connection, a New York-based
advocacy group focused on maternity care. “The payors are
finally saying, ‘Enough is enough. This is crazy.’”

As costs climb, insurers are shedding a reluctance to
intervene in an area as sensitive as childbirth, Corry said.
Aetna, the third-biggest U.S. health plan, is seeking to adjust
prices for cesareans, which now earn hospitals as much as twice
the rate of traditional deliveries. Cigna is considering a
similar move, along with bonuses for hospitals that reduce early
C-sections and inductions.

Carriers led by UnitedHealth Group Inc., the biggest U.S.
insurer, gave $60,000 in 2009 for a symposium on maternity care
run by Childbirth Connection, a 94-year-old nonprofit mostly
funded by foundation grants. States are taking action as well:
Texas lawmakers voted last year to limit payments for the
procedures from Medicaid, the health program for the poor.

Expensive Births

The average cesarean birth cost $24,300 in the U.S. last
year, compared with $15,200 for a vaginal birth, according to
the London-based International Federation of Health Plans.

The industry efforts, joined by public-health groups and
charities like the March of Dimes Foundation, come as early
births not only proliferate but move further from the 39 weeks
considered optimal for single-baby pregnancies.

“It’s been a slippery slope where we’ve said ‘Let’s induce
at 39 and a half weeks. OK, that worked well, let’s try 38;
let’s try 37,’” said Elliott Main, chairman of obstetrics and
gynecology at California Pacific Medical Center in San
Francisco. “Year after year, it’s gotten pushed back.”

C-sections and inductions have risen for a variety of
reasons. Women are giving birth later in life, patients and
doctors are seeking more convenience and payment systems often
favor intervention. There’s also been a growing sense -- false,
based on recent research -- that cesareans offer a risk-free
alternative to natural birth, said Patricia Stephenson, a senior
medical director at Bloomfield, Connecticut-based Cigna.

‘Convenience-Oriented’

“Society is becoming increasingly convenience-oriented,”
said Stephenson, a former obstetrician. “If there’s any concern
about the pregnancy, if the mom is uncomfortable, it’s been,
‘Sure, why not? Just suggest an early delivery.’”

The procedures, of course, make sense when the health of
the mother or baby is at risk. C-sections, for example, may be
necessary for breech babies improperly positioned in the birth
canal or when women suffer from severe high-blood pressure,
according to the American College of Obstetrics and Gynecology.

Still, such cases can not explain the rise to a record 33
percent of U.S. babies delivered by cesarean in 2009, the latest
figures available from the U.S. Centers for Disease Control and
Prevention. Induction rates rose to 23 percent that year,
doubling over two decades, the Atlanta-based CDC said.

’Epidemic Proportions’

The U.S. isn’t alone in bending Mother Nature to modern
medicine. Cesarean levels have reached “epidemic proportions”
in many countries, the World Health Organization said in a
report two years ago. The U.S. rate is on par with some Latin
American nations and Australia but well ahead of the U.K.,
France and Norway, all with cesarean rates at 22 percent or
less, the WHO said.

The backlash against the procedures has spawned its own
website, The Unnecesarean, where San Diego mom Jill Arnold
shares tales of women who felt pushed into C-sections.

Arnold, 38, was persuaded by doctors to schedule a cesarean
in 2005 after being told her baby might be too large, she said.
She went into labor before the operation and delivered her
daughter, Maggie, normally and without incident.

Two years later, she gave birth to a second girl, Molly, at
an independent birth-center where she felt “more in control.”
She started the website after hearing from other mothers who
felt pressured while finding more research that questioned the
approach.

Patients ‘Railroaded’

“They feel either lied to or deceived or that they were
pushed really heavily in one direction and later found out the
medical indication wasn’t there,” Arnold said. “They feel they
were railroaded.”

It’s only recently that research has shown the tradeoffs of
cutting pregnancy short by a few days, Stephenson said. A 2009
study in the New England Journal of Medicine found rates of
medical problems doubled for children born at 38 weeks compared
with those delivered at 39 weeks. At 37 weeks, the risk of
complications, including breathing problems and infection, rose
by as much as four times. The study was sponsored by the
National Institutes of Health.

Inductions can lead to longer, more painful deliveries that
studies show are twice as likely as spontaneous labor to end in
a C-section, said Main, the San Francisco doctor.

Hospital Survey

While there is no nationwide count of the practice, a
survey of hospitals last year by the nonprofit Leapfrog Group
found 14 percent of C-sections and inductions were performed for
nonmedical reasons before 39 weeks. That may underestimate the
phenomenon, since hospitals that track early procedures are also
likely to be the ones concerned about limiting them, said Erica
Newman, a program director at the Washington-based group.

Among obstetricians, “people are worried” about the early
births, said Joshua Copel, a Yale University professor and
former president of the U.S. Society for Maternal-Fetal
Medicine. “For anything elective, most of us believe that 39
weeks and zero days is the absolute earliest any delivery should
occur.”

Insurers are trying to shift what Main calls the “perverse
incentives” that push doctors to speed up deliveries. C-sections not only pay more; along with inductions they also
allow doctors to cluster births and schedule other visits around
them, he said. And they assure a physician will be on hand for a
delivery -- and get the insurance payment -- when a baby
arrives. Wary of litigation, many hospitals also refuse to do
vaginal births if a mom has had a prior C-section, even when
natural delivery is a viable option, Main said.

Aetna Payments

Aetna has renegotiated maternity payments with 10 hospitals
around the country so far, bringing rates for cesareans and
vaginal births closer together, said Tammy Arnold, a spokeswoman
for the Hartford, Connecticut-based carrier.

The company is also highlighting hospitals that adopt
guidelines designed to avoid elective births before 39 weeks,
Arnold said in a telephone interview. So far, about 300
hospitals have won the designation.

Cigna is pursuing similar changes. While it expects some
resistance from hospitals, research on the benefits of full-term
births is winning over physicians, Stephenson said. The insurer
has seen a decline in early elective procedures in the last few
years, she said.

UnitedHealth has taken “more of a carrot approach,” said
Tina Groat, the company’s national medical director for women’s
health. While the Minnetonka, Minnesota-based insurer is
considering bonuses for providers who reduce elective births, it
has so far focused on educational campaigns, including videos
and websites geared toward pregnant women.

Hospitals are acting as well, said Joanne Rogovoy, a state
program director for the March of Dimes, the White Plains, New
York-based charity seeking to reduce premature births. Since
August, the group’s Oregon chapter has persuaded 34 hospitals in
the state to bar elective C-sections before 39 weeks.

“We schedule everything,” said Rogovoy, who’s based in
Portland. “We’ve just become complacent. And it’s only recently
that it’s become clear how much of a difference a few weeks can
make.”